Job Summary and Essential Function

The Care Coordination MSW Social Worker works in collaboration with a multidisciplinary team of clinicians as part of the Care Coordination program to provide high quality, outcome-based, patient-centered care and address the social determinants of health to support safe transitions of care across the continuum for patients and families throughout Atlantic Health System.

Job Responsibilities along with a percentage of time performing duties

60% - Patient assessment, referrals, intervention

20% - Documentation

10% - Meetings, program development

10%- Collaboration with inside/outside agencies

Job Function: 01.

Support high-cost/high-risk patients to address barriers to care and navigation challenges across the care continuum by prioritizing health and SDOH needs, addressing gaps in internal and external resources, and sustainable connections to medical homes and sustainable social supports to improve the patient experience, achieve better health outcomes, decrease avoidable cost and utilization, and increase the utilization of preventative care and healthy behaviors to improve health.

Job Function: 02.

Provide psychosocial assessment, sustainable care transitions, and structured support to help address social and economic barriers to positive health outcomes and empower patients to set and achieve their individualized health goals. Apply best practice interventions based upon care standards and referral and linkage to services to ensure behavioral and psychosocial needs are addressed, including but not limited to: social needs, financial stressors, difficulty coping, behavioral health concerns or substance misuse, abuse and neglect, interpersonal violence, homelessness, functional decline, frequent ED visits or hospitalization, need for long-term care planning, etc

Job Function 03.

Maintain best practices, process systems, and key performance metrics to provide effective outcome-based, patient-centered care with a focus on culturally-sensitive and inclusive interventions, equitable access to care, and reduction in health disparities. Conduct psychosocial assessment, social determinants of health screening and referral, and develop a plan of care in alignment with individual needs, values, and goals of the patient. Provide individual telephonic/virtual support and counseling to patients, using appropriate therapeutic techniques and evidence-based theories to guide patients toward healthy coping, self-management, and overall wellness. Maintain accurate and timely referral response, assessment, intervention, and documentation, according to department workflow and policy.

Job Function 04.

Ensure ongoing collaboration and communication with the larger interdisciplinary Care Coordination team, AHS/ACO practices, providers, and care team members to comprehensively address evolving psychosocial needs, medical needs, and plan of care. Maintain a current knowledge base of community agencies and key contacts and assist with patient advocacy, navigation, and engagement with sustainable medical, social, insurance and benefit systems.

Job Function: 05.

Regularly attend and actively participate in assigned intradisciplinary and interdisciplinary forums, administrative meetings, staff meetings, supervisory sessions, and in-service training. Provide consultative support for department community health workers through education, training and one to one case oversight. Annually participate in a minimum of 3 educational programs on topics relevant to practice area.

Job Function: 06.

Other tasks as required by manager, director, or leadership.

Required:

1. MSW from an accredited school of social work.

2. NJ LSW or LCSW required.

Preferred:

Exceptional organizational and time management skills with the ability to multi-task, problem-solve, and balance and deliver results in a program with multiple projects, programs, and priorities.

Strong clinical, interpersonal, and analytical skills with clear verbal, telephonic and written communication.

Ability to function within an interdisciplinary team and develop and enhance collaborations with local community agencies and organizations.

Ability to navigate EMR and databases with demonstrated ability, including EMR documentation standards, Microsoft Office suite and metrics/outcome reporting.

Strong interpersonal and communication skills, problem solving, ability to work with diverse populations, compassionate service delivery. Bilingual a plus.

ABOUT US

At Atlantic Health System, our promise to our communities is; Anyone who enters one of our facilities, will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 20,000 team members. Headquartered in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include:

• Morristown Medical Center, Morristown, NJ

• Overlook Medical Center, Summit, NJ

• Newton Medical Center, Newton, NJ

• Chilton Medical Center, Pompton Plains, NJ

• Hackettstown Medical Center, Hackettstown, NJ

• Goryeb Children's Hospital, Morristown, NJ

• CentraState Healthcare System, Freehold, NJ

• Atlantic Home Care and Hospice

• Atlantic Mobile Health

• Atlantic Rehabilitation

We also have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. Atlantic Accountable Care Organization is one of the largest ACOs in the nation, and we are a member of AllSpire Health Partners.

We have received awards and recognition for the services we have provided to our patients, team members and communities. Below are just a few of our accolades:

• 100 Best Companies to Work For ® and FORTUNE® magazine for 15 years

• Best Places to Work in Healthcare - Modern Healthcare

• 150 Top Places to work in Healthcare - Becker's Healthcare

• 100 Accountable Care Organizations to Know - Becker's Hospital Review

• Best Employers for Workers over 50 - AARP

• Gold-Level "Well Workplace": Wellness Council of America (WELCOA)

• One of the 100 Best Workplaces for “Millennials” Great Place to Work® and FORTUNE® magazine

• One of the 20 Best Workplaces in Health Care: Great Place to Work® and FORTUNE® magazine

• Official Health Care Partner of the New York Jets

• NJ Sustainable Business

Morristown Medical Center is a nationally-recognized leader in cardiology and heart surgery, orthopedics, gynecology, geriatrics, gastroenterology and GI surgery, pulmonology and lung surgery, and urology.

We are the only hospital in New Jersey named one of America's '50 Best Hospitals' for six consecutive years by Healthgrades and one of the World's Best Hospitals by Newsweek. We were included on Becker's Healthcare 2020 list of "100 Great Hospitals in America". In addition, Leapfrog recognized us with an "A" hospital safety grade - its highest - twelve consecutive times, and the Centers for Medicare and Medicaid Services awarded us again with its highest five-start rating in 2020.

Morristown Medical Center is a Magnet Hospital for Excellence in Nursing Service, the highest level of recognition achievable from the American Nurses Credentialing Center for facilities that provide acute care services. Our nonprofit hospital was also designated a Level I Regional Trauma Center by the American College of Surgeons and a Level II by the State of NJ.

EEO STATEMENT

Atlantic Health System, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran status.